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1 Clin Orthop Relat Res (2015) 473: / DOI /s Clinical Orthopaedics and Related Research A Publication of The Association of Bone and Joint Surgeons Published online: 6 January 2015 Ó The Association of Bone and Joint Surgeons : Intramedullary Nails for Extracapsular Hip Fractures in Adults (Review) Nathan Evaniew MD, Mohit Bhandari MD, PhD, FRCSC Importance of the Topic More than 1.5 million patients suffer hip fractures worldwide each year [3], and annual direct and indirect costs are A Note from the Editor-In-Chief: We are pleased to publish the next installment of 1, our partnership between CORR 1, The Cochrane Collaboration 1, and McMaster University s Evidence-Based Orthopaedics Group. In it, researchers from McMaster University will provide expert perspective on an abstract originally published in The Cochrane Library that we think is especially important. (Queally JM, Harris E, Handoll HHG, Parker MJ. Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD DOI: / CD pub4). Copyright Ó 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Reproduced with permission. NE certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. One of the authors certifies that he (MB), or a member of his or her immediate family, has received or may receive payments or benefits, during the study period, an amount of less projected to exceed USD 130 billion globally by 2050 [6]. Thirty-day mortality approaches 5% in males and 9% in females, and many more patients experience significant functional loss and debilitation [4]. Approximately 50% of all hip fractures are than USD 10,000 from Stryker Corporation (Kalamazoo, MI, USA). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR 1 or the Association of Bone and Joint Surgeons 1. Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library ( should be consulted for the most recent version of the review. This 1 column refers to the abstract available at: DOI: / CD pub4. N. Evaniew MD (&), M. Bhandari MD, PhD, FRCSC Center for Evidence-Based Orthopaedics, Division of Orthopaedics, Department of Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 8E7, Canada nathan.evaniew@medportal.ca extracapsular, which surgeons can treat using a wide variety of possible internal fixation strategies. Extramedullary sliding hip screws were the standard of care from the 1950s to the 1990s, but many surgeons now prefer intramedullary nails that interlock proximally in the femoral head [2]. There has been a more than 20-fold relative increase in the utilization of intramedullary nails since 1999, and approximately two-thirds of new orthopaedic surgeons now select them routinely [1]. Several designs are on the market from different manufacturers, each varying in length, diameter, neckshaft angle, number of locking screws or blades, ability to slide and/or compress, ability to control rotation, construction materials, start-point, and surgical technique. This review aimed to determine whether different nail designs are associated with unique benefits or harms in patients with extracapsular hip fractures. Twelve designs were evaluated among 2130 patients from 17 separate trials. The authors concluded that there were no important differences in function, mobility, pain, death, fracture fixation complications, or rates of revision surgery between most of the implants that were studied.

2 768 Evaniew and Bhandari Clinical Orthopaedics and Related Research 1 Upon Closer Inspection Extracapsular hip fractures include pertrochanteric simple fractures (AO classification 31-A1), pertrochanteric multifragmentary fractures (31-A2), intertrochanteric fractures (31-A3), and subtrochanteric fractures (32-A/B/ C[1 3].1). Reverse obliquity intertrochanteric fractures, intertrochanteric fractures with subtrochanteric extension, and subtrochanteric fractures each carry a worse prognosis than A1 or A2 fractures [7, 8], and unequal inclusion of patients with these fractures in the primary trials could bias the pooled results towards worse outcomes for the treatment group that has more of them. In order to avoid this problem, the authors attempted to separate the results for patients with subtrochanteric fractures from the results for patients with intertrochanteric and pertrochanteric fractures. These types of secondary analyses are commonly referred to as a subgroup analyses and they are frequently used to address specific questions about particular patient groups, types of intervention, or types of study designs. There are two important ways that subgroup analyses can be problematic. First, subgroup analyses are rarely powered adequately, which leaves them at risk of failing to identify important differences between treatment groups (Type II error). Second, testing multiple subgroups raises the possibility of identifying spurious but statistically significant differences due to chance alone, simply because there have been more rolls of the dice (Type I error) [11]. Readers can distinguish credible from less-credible subgroup claims by looking for hypotheses that were formulated before collecting the data, are supported by background literature and/or biological rationale, and are consistent across studies. The direction of a potential subgroup effect should be also prespecified and only a small number of carefully considered hypotheses should be considered. The proposed subgroup for subtrochanteric fractures met many of these criteria, but there was insufficient data in the primary trials to test it. As such, this metaanalysis does not inform whether certain nails might be better suited to specific fractures [9]. Take-Home Messages Overall confidence in the pooled results was addressed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach [5]. Confidence ratings are important because they reflect variations in the design of the primary studies, the risk of bias within and across the primary studies, the degree of imprecision in the pooled results, inconsistency, and indirectness. The GRADE approach has been adopted by more than 70 major health research organizations because it is transparent, structured, and comprehensive enough to guide treatment recommendations. The quality of the evidence for most comparisons in this metaanalysis was low or very low, which indicates that our confidence in the pooled effect estimates is actually limited and that the pooled estimates might differ substantially from reality. In comparison to sliding hip screws, the potential advantages of nailing include a shorter and more rigid moment arm and the contention that insertion is less invasive. However, nails cost between USD 700 and USD 1700 more per implant than sliding hip screws [12] and patientimportant functional outcomes across most fracture patterns are similar in the current literature [10]. A recent economic evaluation found that intramedullary nail fixation was routinely cost-effective only for A3 fractures while sliding hip screw fixation was favored for all A1 fractures and most A2 fractures [12], but these conclusions were highly sensitive to the fixation failure rates. Given that older nails were associated with more reoperations and intra and postoperative fractures, and that modern nails and increased clinical experience may have solved these issues [2], further research

3 Volume 473, Number 3, March comparing modern nails against sliding hip screws is likely to be of substantial value. At least one adequately powered multicenter randomized trial is currently registered and underway (NCT ), but additional trials and other study designs will also be needed to evaluate varying fracture patterns across different patient populations.

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8 774 Evaniew and Bhandari Clinical Orthopaedics and Related Research 1 References 1. Anglen JO, Weinstein JN, American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: Changing pattern of practice. A review of the American board of orthopaedic surgery database. JBone Joint Surg Am. 2008;90: Bhandari M, Schemitsch E, Jonsson A, Zlowodzki M, Haidukewych GJ. Gamma nails revisited: Gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: A meta-analysis. J Orthop Trauma. 2009;23: Bhandari M, Sprague S, Schemitsch EH, International Hip Fracture Research Collaborative. Resolving controversies in hip fracture care: The need for large collaborative trials in hip fractures. J Orthop Trauma. 2009;23: Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the united states. JAMA. 2009;302: Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke R, Rind D, Meerpohl J, Dahm P, Schünemann HJ. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64: Johnell O. The socioeconomic burden of fractures: Today and in the 21st century. Am J Med. 1997;103: 20S,25S; discussion 25S 26S. 7. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable pertrochanteric femoral fractures. J Orthop Trauma. 2014;28 Suppl 8:S Kuzyk PR, Bhandari M, McKee MD, Russell TA, Schemitsch EH. Intramedullary versus extramedullary fixation for subtrochanteric femur fractures. J Orthop Trauma. 2009; 23: Okcu G, Ozkayin N, Okta C, Topcu I, Aktuglu K. Which implant is better for treating reverse obliquity fractures of the proximal femur: A standard or long nail? Clin Orthop Relat Res. 2013;471: Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010(9:CD000093). 11. Sun X, Ioannidis JP, Agoritsas T, Alba AC, Guyatt G. How to use a subgroup analysis: Users guide to the medical literature. JAMA. 2014;311: Swart E, Makhni EC, Macaulay W, Rosenwasser MP, Bozic KJ. Costeffectiveness analysis of fixation options for intertrochanteric hip fractures. J Bone Joint Surg Am. 2014;96: